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An investigation of implicit bias about bending and lifting

  • Roberto Costa Krug EMAIL logo , Marcelo Faria Silva , Ottmar V. Lipp , Peter B. O’Sullivan , Rosicler Almeida , Ian Sulzbacher Peroni and J. P. Caneiro



Previous studies in a high-income country have demonstrated that people with and without low back pain (LBP) have an implicit bias that bending and lifting with a flexed lumbar spine is dangerous. These studies present two key limitations: use of a single group per study; people who recovered from back pain were not studied. Our aims were to evaluate: implicit biases between back posture and safety related to bending and lifting in people who are pain-free, have a history of LBP or have current LBP in a middle-income country, and to explore correlations between implicit and explicit measures within groups.


Exploratory cross-sectional study including 174 participants (63 pain-free, 57 with history of LBP and 54 with current LBP). Implicit biases between back posture and safety related to bending and lifting were assessed with the Implicit Association Test (IAT). Participants completed paper-based (Bending Safety Belief [BSB]) and online questionnaires (Tampa Scale of Kinesiophobia; Back Pain Attitudes Questionnaire).


Participants displayed significant implicit bias between images of round-back bending and lifting and words representing “danger” (IATD-SCORE: Pain-free group: 0.56 (IQR=0.31–0.91; 95% CI [0.47, 0.68]); history of LBP group: 0.57 (IQR=0.34–0.84; 95% CI [0.47, 0.67]); current LBP group: 0.56 (IQR=0.24–0.80; 95% CI [0.39, 0.64])). Explicit measures revealed participants hold unhelpful beliefs about the back, perceiving round-back bending and lifting as dangerous (BSBthermometer: Pain-free group: 8 (IQR=7–10; 95% CI [7.5, 8.5]); history of LBP group: 8 (IQR=7–10; 95% CI [7.5, 9.0]); current LBP group: 8.5 (IQR=6.75–10; [7.5, 9.0])). There was no correlation between implicit and explicit measures within the groups.


In a middle-income country, people with and without LBP, and those who recovered from LBP have an implicit bias that round-back bending and lifting is dangerous.

Corresponding author: Roberto Costa Krug, Physical Therapy Department, Graduate Program in Rehabilitation Sciences, Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Rua Sarmento Leite, 245, Centro Histórico, CEP 90050-170, Porto Alegre, RS, Brazil, E-mail:

  1. Research funding: R.C. Krug received a Master’s scholarship from the Coordination for the Improvement of Higher Education Personnel (CAPES).

  2. Author contributions: All the authors have made substantial contributions to the study: (1) the conception and design of the study (RCK, JPC, MFS), acquisition (RCK, RA, ISP), analysis and interpretation of data (RCK, JPC, OVL), (2) drafting the manuscript or revising it critically for important intellectual content (RCK, JPC, OVL, MFS, POS).

  3. Competing interests: R.C. Krug, J.P. Caneiro and Peter O’Sullivan deliver educational workshops on patient-centred care for the management of pain. All the other authors declare no conflict of interest.

  4. Informed consent: Participants were asked for their informed consent, and were informed that they could withdraw from the study at any time.

  5. Ethical approval: This project was approved by the Research Ethics Committee from the Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Brazil, approval number 3.458.845/CAEE 03952718.0.0000.5345.


Table 4:

Correlations among explicit measures.

Pain-free group BSBthermometer r −0.022 −0.259* −0.183
p-value 0.863 0.041 0.152
IC95% −0.269 0.227 −0.476 −0.012 −0.412 0.068
TSK r −0.296* −0.207
p-value 0.019 0.104
IC95% −0.506 −0.052 −0.432 0.043
BACK-PAQ-Br r 0.647**
p-value 0.000
IC95% 0.432 0.043
History of LBP group BSBthermometer r 0.276* −0.263* −0.253
p-value 0.038 0.048 0.058
IC95% 0.017 0.501 −0.490 −0.002 −0.482 −0.008
TSK r −0.485** −0.298*
p-value 0.000 0.024
IC95% −0.662 −0.257 −0.518 −0.041
BACK-PAQ-Br r 0.740**
p-value 0.000
IC95% 0.594 0.839
Current LBP group BSBthermometer r 0.197 −0.394* −0.295*
p-value 0.153 0.003 0.030
IC95% −0.075 0.442 −0.599 −0.141 −0.522 −0.030
TSK r −0.437** 0.036
p-value 0.001 0.798
IC95% −0.631 −0.192 −0.234 0.301
BACK-PAQ-Br r 0.658**
p-value 0.000
IC95% 0.474 0.787
  1. r values are Spearman’s correlation coefficient; 95% CI, 95% confidence interval; BSBthermometer, Bending Safety Belief; TSK, Tampa Scale of Kinesiophobia; Back-PAQ-Br, Back Pain Attitudes Questionnaire – Brazilian version; Back-PAQ-BrDanger, Subscale of Back-PAQ-Br; *Correlation is significant at the 0.05 level (2-tailed). **Correlation is significant at the 0.01 level (2-tailed). Correlation criteria (r values): very weak: 0.00–0.30; weak: 0.31–0.50; moderate: 0.51–0.70; strong: 0.71–0.90; very strong: greater than 0.90 [36].


1. Maher, C, Underwood, M, Buchbinder, R. Non-specific low back pain. Lancet 2017;389:736–47. in Google Scholar

2. Steffens, D, Ferreira, ML, Latimer, J, Ferreira, PH, Koes, BW, Blyth, F, et al.. What triggers an episode of acute low back pain? A case-crossover study. Arthritis Care Res 2015;67:403–10. in Google Scholar PubMed

3. Nachemson, A. The influence of spinal movements on the lumbar intradiscal pressure and on the tensil stresses in the annulus fibrosus. Acta Orthop Scand 1963;33:183–207. in Google Scholar PubMed

4. Nachemson, A. The load on lumbar disks in different positions of the body. Clin Orthop Relat Res 1966;45:107–22. in Google Scholar

5. HSE. Manual handling: manual handling operations regulations 1992, 4th ed. London: HSE Books; 2016.Search in Google Scholar

6. NIOSH. Ergonomic guidelines for manual materials handling. California: DHHS (NIOSH); 2007.Search in Google Scholar

7. Stevens, ML, Steffens, D, Ferreira, ML, Latimer, J, Li, Q, Blyth, F, et al.. Patients’ and physiotherapists’ views on triggers for low back pain. Spine (Phila Pa 1976) 2016;41:E218–24. in Google Scholar PubMed

8. Nolan, D, O’Sullivan, K, Stephenson, J, O’Sullivan, P, Lucock, M. What do physiotherapists and manual handling advisors consider the safest lifting posture, and do back beliefs influence their choice? Musculoskelet Sci Pract 2018;33:35–40. in Google Scholar PubMed

9. Darlow, B, Dean, S, Perry, M, Mathieson, F, Baxter, GD, Dowell, A. Easy to harm, hard to heal: patient views about the back. Spine (Phila Pa 1976) 2015;40:842–50. in Google Scholar PubMed

10. Saraceni, N, Kent, P, Ng, L, Campbell, A, Straker, L, O’Sullivan, P. To flex or not to flex? Is there a relationship between lumbar spine flexion during lifting and low back pain? A systematic review with meta-analysis. J Orthop Sports Phys Ther 2020;50:121–30. in Google Scholar PubMed

11. Nolan, D, O’Sullivan, K, Newton, C, Singh, G, Smith, BE. Are there differences in lifting technique between those with and without low back pain? A systematic review. Scand J Pain 2020;20:215–27. in Google Scholar PubMed

12. Bunzli, S, Smith, A, Schütze, R, Sullivan, P. Beliefs underlying pain-related fear and how they evolve: a qualitative investigation in people with chronic back pain and high pain-related fear. BMJ Open 2015;5:e008847. in Google Scholar PubMed PubMed Central

13. Vlaeyen, JWS, Crombez, G, Linton, SJ. The fear-avoidance model of pain. Pain 2016;157:1588–9. in Google Scholar

14. Melzer, A, Shafir, T, Tsachor, RP. How do we recognize emotion from movement? Specific motor components contribute to the recognition of each emotion. Front Psychol 2019;10:1389. in Google Scholar

15. Paloutzian, RF, Park, CL. Religiousness and spirituality: the psychology of multilevel meaning-making behavior. Relig Brain Behav 2015;5:166–78. in Google Scholar

16. Dasgupta, N, Aizen, I. Explicit and implicit beliefs, attitudes, and intentions: the role of conscious and unconscious processes in human behavior. In: The Sense of Agency. Cambridge: Cambridge University Press; 2015.Search in Google Scholar

17. Seitz, RJ, Paloutzian, RF, Angel, H-F. Processes of believing: where do they come from? What are they good for? F1000Res 2016;5:2573. in Google Scholar

18. Caneiro, JP, O’Sullivan, P, Smith, A, Moseley, GL, Lipp, OV. Implicit evaluations and physiological threat responses in people with persistent low back pain and fear of bending. Scand J Pain 2017;17:355–66. in Google Scholar

19. Caneiro, JP, O’Sullivan, P, Lipp, OV, Mitchinson, L, Oeveraas, N, Bhalvani, P, et al.. Evaluation of implicit associations between back posture and safety of bending and lifting in people without pain. Scand J Pain 2018;18:719–28. in Google Scholar

20. Caneiro, JP, O’Sullivan, P, Smith, A, Ovrebekk, IR, Tozer, L, Williams, M, et al.. Physiotherapists implicitly evaluate bending and lifting with a round back as dangerous. Musculoskelet Sci Pract 2019;39:107–14. in Google Scholar

21. Foster, NE, Anema, JR, Cherkin, D, Chou, R, Cohen, SP, Gross, DP, et al.. Prevention and treatment of low back pain: evidence, challenges, and promising directions. Lancet 2018;391:2368–83. in Google Scholar

22. Dionne, CE, Dunn, KM, Croft, PR, Nachemson, AL, Buchbinder, R, Walker, BF, et al.. A consensus approach toward the standardization of back pain definitions for use in prevalence studies. Spine (Phila Pa 1976) 2008;33:95–103. in Google Scholar PubMed

23. Greenwald, AG, McGhee, DE, Schwartz, JL. Measuring individual differences in implicit cognition: the implicit association test. J Pers Soc Psychol 1998;74:1464–80. in Google Scholar

24. Bunzli, S, Smith, A, Watkins, R, Schutze, R, O’Sullivan, P. What do people who score highly on the Tampa scale of Kinesiophobia really believe?: A mixed methods investigation in people with chronic nonspecific low back pain. Clin J Pain 2015;31:621–32. in Google Scholar

25. Mallan, K, Lipp, O. Does emotion modulate the blink reflex in human conditioning? Startle potentiation during pleasant and unpleasant cues in the picture–picture paradigm. Psychophysiology 2007;44. in Google Scholar PubMed

26. Forster, KI, Forster, JC. DMDX: a windows display program with millisecond accuracy. Behav Res Methods Instrum Comput 2003;35:116–24. in Google Scholar PubMed

27. Lane, KA, Banaji, MR, Nosek, BA, Greenwald, AG. Understanding and using the Implicit Association Test: IV: What we know (so far) about the method. Implicit measures of attitudes. New York, NY, US: The Guilford Press; 2007. p. 59–102.Search in Google Scholar

28. Nosek, BA, Greenwald, AG, Banaji, MR. Understanding and using the Implicit Association Test: II. Method variables and construct validity. (0146-1672 (Print)). Pers Soc Psychol Bull 2005;31:166–80. in Google Scholar PubMed

29. Darlow, B, Perry, M, Mathieson, F, Stanley, J, Melloh, M, Marsh, R, et al.. The development and exploratory analysis of the Back Pain Attitudes Questionnaire (Back-PAQ). BMJ Open 2014;4:e005251. in Google Scholar PubMed PubMed Central

30. Krug, RC, Caneiro, JP, Ribeiro, DC, Darlow, B, Silva, MF, Loss, JF. Back pain attitudes questionnaire: cross-cultural adaptation to Brazilian-Portuguese and measurement properties. Braz J Phys Ther 2020;25:271–80. in Google Scholar PubMed PubMed Central

31. Miller, RP, Kori, SH, Todd, DD. The Tampa scale: a measure of kinisophobia. Clin J Pain 1991;7:51. in Google Scholar

32. Houben, RM, Leeuw, M, Vlaeyen, JW, Goubert, L, Picavet, HS. Fear of movement/injury in the general population: factor structure and psychometric properties of an adapted version of the Tampa Scale for Kinesiophobia. J Behav Med 2005;28:415–24. in Google Scholar PubMed

33. Houben, RMA, Ostelo, RWJG, Vlaeyen, JWS, Wolters, PMJC, Peters, M, den Berg, SGMS-v. Health care providers’ orientations towards common low back pain predict perceived harmfulness of physical activities and recommendations regarding return to normal activity. Eur J Pain 2005;9:173–83. in Google Scholar PubMed

34. de Souza, FS, Marinho, C da S, Siqueira, FB, Maher, CG, Costa, LO. Psychometric testing confirms that the Brazilian-Portuguese adaptations, the original versions of the Fear-Avoidance Beliefs Questionnaire, and the Tampa Scale of Kinesiophobia have similar measurement properties. Spine (Phila Pa 1976) 2008;33:1028–33. in Google Scholar PubMed

35. Siqueira, FB, Teixeira-Salmela, LF, Magalhães, LdC. Análise das propriedades psicométricas da versão brasileira da escala tampa de cinesiofobia. Acta Ortop Bras 2007;15:19–24. in Google Scholar

36. Hinkle, DE, Wiersma, W, Jurs, SG. Applied statistics for the behavioral sciences. Boston, Massachusetts: Houghton Mifflin; 2003.Search in Google Scholar

37. Ferguson, CJ. An effect size primer: a guide for clinicians and researchers. Prof Psychol Res Pract 2009;40:532–8. in Google Scholar

38. Meulders, A. Fear in the context of pain: lessons learned from 100 years of fear conditioning research. Behav Res Ther 2020;131:103635. in Google Scholar

39. Caneiro, JP, Bunzli, S, O’Sullivan, P. Beliefs about the body and pain: the critical role in musculoskeletal pain management. Braz J Phys Ther 2020;25:17–29. 10.1016/j.bjpt.2020. in Google Scholar

40. Gross, DP, Ferrari, R, Russell, AS, Battié, MC, Schopflocher, D, Hu, RW, et al.. A population-based survey of back pain beliefs in Canada. Spine (Phila Pa 1976) 2006;31:2142–5. in Google Scholar

41. Matheve, T, De Baets, L, Bogaerts, K, Timmermans, A. Lumbar range of motion in chronic low back pain is predicted by task-specific, but not by general measures of pain-related fear. Eur J Pain 2019;23:1171–84. in Google Scholar

42. Vlaeyen, JW, Linton, SJ. Fear-avoidance and its consequences in chronic musculoskeletal pain: a state of the art. Pain 2000;85:317–32. in Google Scholar

43. Bunzli, S, Watkins, R, Smith, A, Schutze, R, O’Sullivan, P. Lives on hold: a qualitative synthesis exploring the experience of chronic low-back pain. Clin J Pain 2013;29:907–16. in Google Scholar

44. Knechtle, D, Schmid, S, Suter, M, Riner, F, Moschini, G, Senteler, M, et al.. Fear avoidance beliefs limit lumbar spine flexion during object lifting in pain-free adults. medRxiv 2020:2020.04.01.20049999.10.1101/2020.04.01.20049999Search in Google Scholar

45. Karayannis, NV, Smeets, RJ, van den Hoorn, W, Hodges, PW. Fear of movement is related to trunk stiffness in low back pain. PLoS One 2013;8:e67779. in Google Scholar PubMed PubMed Central

46. Moseley, GL, Nicholas, MK, Hodges, PW. Does anticipation of back pain predispose to back trouble? Brain 2004;127:2339–47. in Google Scholar PubMed

47. Bunzli, S, Smith, A, Schutze, R, Lin, I, O’Sullivan, P. Making sense of low back pain and pain-related fear. J Orthop Sports Phys Ther 2017;47:628–36. in Google Scholar PubMed

48. O’Sullivan, PB, Caneiro, JP, O’Keeffe, M, Smith, A, Dankaerts, W, Fersum, K, et al.. Cognitive functional therapy: an integrated behavioral approach for the targeted management of disabling low back pain. Phys Ther 2018;98:408–23. in Google Scholar PubMed PubMed Central

49. Hofmann, W, Gawronski, B, Gschwendner, T, Le, H, Schmitt, M. A meta-analysis on the correlation between the implicit association test and explicit self-report measures. Pers Soc Psychol Bull 2005;31:1369–85. in Google Scholar PubMed

50. Gawronski, B, Bodenhausen, GV. Associative and propositional processes in evaluation: an integrative review of implicit and explicit attitude change. Psychol Bull 2006;132:692–731. in Google Scholar PubMed

51. Ahenkorah, J, Moffatt, F, Diver, C, Ampiah, PK. Chronic low back pain beliefs and management practices in Africa: time for a rethink? Musculoskeletal Care 2019;17:376–81. in Google Scholar PubMed

52. Verbeek, JH, Martimo, KP, Karppinen, J, Kuijer, PP, Viikari-Juntura, E, Takala, EP. Manual material handling advice and assistive devices for preventing and treating back pain in workers. Cochrane Database Syst Rev 2011:Cd005958. in Google Scholar PubMed

53. Wai, EK, Roffey, DM, Bishop, P, Kwon, BK, Dagenais, S. Causal assessment of occupational lifting and low back pain: results of a systematic review. Spine J 2010;10:554–66. in Google Scholar PubMed

54. Saraceni, N, Campbell, A, Kent, P, Ng, L, Straker, L, O’Sullivan, P. Exploring lumbar and lower limb kinematics and kinetics for evidence that lifting technique is associated with LBP. PLoS One 2021;16:e0254241. in Google Scholar PubMed PubMed Central

55. Buchbinder, R, Underwood, M, Hartvigsen, J, Maher, CG. The Lancet Series call to action to reduce low value care for low back pain: an update. Pain 2020;161(Suppl 1):S57–S64. in Google Scholar PubMed PubMed Central

56. Briggs, AM, Huckel Schneider, C, Slater, H, Jordan, JE, Parambath, S, Young, JJ, et al.. Health systems strengthening to arrest the global disability burden: empirical development of prioritised components for a global strategy for improving musculoskeletal health. BMJ Global Health 2021;6:e006045. in Google Scholar

57. Beales, D, Smith, A, O’Sullivan, P, Hunter, M, Straker, L. Back pain beliefs are related to the impact of low back pain in baby boomers in the Busselton Healthy Aging Study. Phys Ther 2015;95:180–9. in Google Scholar PubMed

58. Smith, AJ, O’Sullivan, PB, Beales, D, Straker, L. Back pain beliefs are related to the impact of low back pain in 17-year-olds. Phys Ther 2012;92:1258–67. in Google Scholar PubMed

59. Buchbinder, R, Jolley, D, Wyatt, M. Population based intervention to change back pain beliefs and disability: three part evaluation. BMJ 2001;322:1516–20. in Google Scholar PubMed PubMed Central

60. Traeger, AC, Lee, H, Hübscher, M, Skinner, IW, Moseley, GL, Nicholas, MK, et al.. Effect of intensive patient education vs placebo patient education on outcomes in patients with acute low back pain: a randomized clinical trial. JAMA Neurol 2019;76:161–9. in Google Scholar PubMed PubMed Central

61. Lee, H, Mansell, G, McAuley, JH, Kamper, SJ, Hübscher, M, Moseley, GL, et al.. Causal mechanisms in the clinical course and treatment of back pain. Best Pract Res Clin Rheumatol 2016;30:1074–83. in Google Scholar PubMed

Received: 2021-08-16
Accepted: 2021-11-03
Published Online: 2021-11-24
Published in Print: 2022-04-26

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